Knowing Nursing through its Evolutionary Descriptions: The Definitions of Nursing
By Dr. Evalyn E. Abalos, Acting Dean, College of Nursing
(The paper below was submitted for publication in the Silliman Journal.)
“The glorious thing about nursing is that it cannot be defined. The irony is that we never give up trying.”
(F. Storlie as cited in Brooks & Klein-Kracht, 1983, p. 61)
The word “nurse” originated from the Latin word nutrix, meaning to nourish (Taylor, Lillis, &LeMone, 1997). Definitions of nurse and nursing are based on this word origin to describe the nurse as a person who nourishes, fosters, and protects—a person prepared to take care of the sick, injured, and aged people (Ellis & Hartley, 2004). Nonetheless, the most recent definition of nursing as defined by the American Nurses Association (ANA) is that it is “the protection, promotion, and optimization of health and abilities, preventions of illness and injury, alleviation of suffering through diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2003, p. 6). Similarly, nursing in the Philippines is defined legally in Republic Act 9173, which is the prevailing law regulating the nursing practice. It states in Article VI, Section 28:
A person is deemed to be practicing nursing when he/she singly, or in collaboration with another, initiates and performs nursing services to individuals, families, and communities in any health care setting …As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. As members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death.
However, how has nursing evolved to be what it is today? What are the historical landmarks of its journey?
This paper aims to present the breadth and depth of the evolutionary ‘journey’ of contemporary definitions of nursing. Knowing this journey can serve as a vehicle to increase the appreciation of nursing history as it has ushered the discipline and profession to the present time, particularly in the Philippine setting. The author attempts to connect the present with the past, believing what Dock and Stewart (as cited in Lindeman &McAthie, 1999) aptly articulated:
No occupation can be intelligently followed or understood unless it is, at least to some extent, illuminated by the light of history interpreted from the human standpoint. The origin of our various activities, the spirit animating the founders of a profession, and the long struggle toward an ideal as revealed by a search in the past – these vivify and enable the most prosaic labors, clarify their relation to all else that humanity is doing, and give to workers an unfailing inspiration in the consciousness of being one part of the great whole. We must know how our work of nursing arose; what lines it has followed and under what direction it has developed best. Possessing the knowledge, each one may help it guide and influence its future in harmony with its historical mission (pp. 3-4).
Evolution of the Definition
Several authors have traced the history and definition of nursing. These historical events will be addressed separately according to specific categories as delineated by particular authors.Brooks &Kleine-Kracht (1983) identified nine eras, starting from the 18th century up to the 1980s, which have brought a keener awareness of the history of nursing in relation to the nurse’s professional role and how the political and social events have shaped the evolution of nursing. Similarly, Berman, Snyder, Kozier, andErb (2008) traced the historical perspectives of nursing in relation to aspects of events that have influenced nursing. These are: women’s roles, religion, war, social attitudes, and nursing leaders. On the other hand, Buenavista, Jr. (n.d.) divided nursing history into four periods: Intuitive, Apprentice, Educative, and Contemporary, while Tomey and Alligood (2002), divided the history of professional nursing into curriculum era, research era, graduate education era, and the theory era. In whatever way its history is traced, the unfolding of nursing is noteworthy to reminisce, although, the definition of nursing is difficult to grasp because it is intertwined with socio-political events, the changing roles of the nurse, the nature and knowledge base of nursing practice, education, and legislation, among others. Added to this, “because of frequent role confusion there continues to be a lack of consensus as to the definition of nursing” (Brooks &Kleine-Kracht, 1983, p. 52).
Prehistoric Era up to the 18th Century
During the prehistoric times, nursing can be construed as an activity—to fix and make humans whole again. Learning how to care for the young may have been learned from animals (White, 2001) and some of the early definitions of the word nurse were “one who cares for or suckles a child” and “one who looks after and fosters” (Lindeman &McAthie, 1999). Nursing was also seen as a religious exercise or a pious act. Those who did nursing functioned under a religious order (White, 2001). During the early civilization, nursing was seen as a religious calling with no formal preparation. Nursing was regarded as a vocation and those who practiced it were willing to deny themselves of the worldly pleasures which required personal sacrifice or being remorseful or repentant and atoning for a sin (Lindeman &McAthie, 1999).
Pious devotion was needed to become a nurse. It is unfortunate though that these religious values often caused exploitation and few monetary rewards for nurses throughout history (Berman et al., 2008). But it was also the Christian value of love which greatly influenced some wealthy persons, such as Fabiola, to provide houses for the poor and homeless (Kozier, Erb, Berman, & Snyder, 2004).
Although olden times also witnessed men who provided nursing such as the Knights of St. John of Jerusalem, most nurses were females who were poorly educated due to societal attitude that the woman’s place was in the home. Nursing then had no social status. ( White, 2004) .
Like in other parts of the world, nursing in the Philippines started during the prehistoric times. The credible archaeological findings point to the fact that Filipinos used customary health practices for the sick inside caves (DeBelen& De Belen, 2007). Early beliefs include attribution of diseases to dwarves(“duwende”), witches(“mangkukulam”), omens (“kutob”), curses (“sumpa”), and evil spirits(“masamangispiritu”) which needed a spin doctor(“herbolario” or “albolario”) to drive the evil spirits. These pagan practices of “nursing” the sick continued until the coming of the Spaniards in the 1500s when Catholic teachings were enforced on the Filipino people (De Belen & De Belen, 2007).
19th century—The Humanistic Influence of Nightingale
This century brought nursing to greater heights with the influence of Florence Nightingale during the mid 19th century. The care of the sick continued for humanitarian reasons and the performance of nursing tasks was “to and for the patient.” As civilization grew, so did population. More and more people experienced sickness and were in need of nursing care. Thus, nursing started to be viewed as a job which needed preparation and training. The training was by apprenticeship. In apprenticeship, one learns exactly what one does and therefore knowing and doing were one and the same (Lindeman &McAthie, 1999). This period set the template for change in the image and status of nursing: the start of modern nursing and its evolution into a profession.
In the mid 1800s in England, Pastor Theodore and FriederikeFliedner started a hospital in Kaiserworth, Germany. They created training programs for nurses when they realized there was no workforce for the hospital. Theodore Fliedner reinstituted the Order of Deaconesses (group of nursing providers) which was suppressed by the western churches. It was with Fliedner’s program that Florence Nightingale “trained” (Lindeman &McAthie, 1999; Berman et al., 2008). Nightingale was later known as “the creator of the standards of modern, Western, secular nursing practice and education” (Selanders, 2010, p. 70). She improved the standards for the care of the wounded soldiers in Crimea which earned her the title “Lady with the Lamp” (Berman et al., 2008). She was a skilled statistician and considered as the first nurse-researcher. Theory development began with the writings of Nightingale (George, 2002).
One of Nightingale’s earliest applications of her nursing care and management skills was done during the Crimean war of Great Britain in 1854.At the request of a friend and Secretary of War, Sidney Herbert, she took care of wounded soldiers. She addressed sanitation problems. Reduced morbidity and mortality resulted from her environmental modifications in the Scutari barracks ( White, 2001; Tomey, et al, 2002). Nightingale attended to the needs of the environment and within six months, the mortality rate dropped to 2% from 42.7%. She returned to England after and used her knowledge and experience in creating hospital reforms for the War Department to consider (Lobo, 2002).
Nightingale believed that the nurse is the one who does “for” the patient as evidenced in her statement: “If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease, but of the nursing”(2005, p. 5). She further stated that “nursing ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient” (p.5). This principle was more of doing “for” the patient, not “with” the patient, as she “for the most part…described a passive patient in this relationship” (Tomey&Alligood, 2002, p. 70). Doing “for” the patient implies that the nurse decides for the patient and prescribes what the nurse thinks is best the patient. On the contrary, doing “with” and being “with” the patient entails collaboration between the patient and the nurse. This is apparent in a contemporary nurse-patient relationship such as described in the theory of Rosemarie Parse wherein she contends that it is not the nurse, but the client, who is the prime decision maker and that nursing is not a prescriptive approach noran offering of professional advice (George, 2002). Rather, “people co-participate in creating what is real for them through self-expression in living their values in a chosen way” (The Nursing Theory Network, 2005, para. 1).
In the United States, the development of nursing was strongly influenced by Nightingale through her personal friend, Dr. Elizabeth Blackwell, the first American woman physician.Their friendship paved the way for the establishment of a school of nursing at the New England Hospital for Women and Children in Boston. Linda Richards was the first nurse to graduate from the program in 1873 and was known as the “first trained nurse in America” (Lindeman &McAthie, 1999). More nursing schools were opened in the United States after the civil war—arecognition of the need for better trained nurses. Three schools - Bellevue Hospital in New York, Connecticut Training School in New Haven, and Boston Training School at Massachusetts General Hospital were opened and were patterned from the Nightingale School. ( Brooks & Klein-Kracht, 1983).
The growth in technology necessitated trained nurses. Findings of a commission in the USA showed that in hospitals where nurses were trained, there was reduction in cost and mortality. This became the basis for the American Medical Association to favor nurses’ training (Brooks & Klein-Kracht, 1983). Most schools, though, were under the control of physicians, and had the apprenticeship form of education based on rules, principles, and traditions (McEwen & Wills, 2007). Nursing education at this time was more of technical knowledge. The focus of nursing education and practice was on technical skills. The growth of nursing collegiate programs was slow as physicians believed that “university-educated nurses were overtrained” ( McEwen & Wills, 2007).
Another milestone was achieved during this century: the emerging professional image of the nurse and the budding professional equality with medicine as commented by Gross (1869 as cited in Brooks & Klein-Kracht, 1983): “nursing in its exact sense is as much of an art and science as is medicine” (p. 54). The end of this century ushered advances for the 20th century.
This century saw nursing as a technical profession. Definitions of nursing after World War II “show a ‘tunneling’ of nursing into a highly technical profession with minimal involvement in the human societal issues” (Brooks & Klein-Kracht, 1983, p. 62). Nursing began to have definitions with scientific basis and the genesis of nursing theories in the 1960s resulted from highly technical nursing (Brooks & Klein-Kracht, 1983). The emergence of nursing science started at this point in history.
In the 1950s Columbia University’s Teachers College developed graduate education programs for administrative and faculty positions. The graduates (e.g., Peplau, Henderson, Hall, Abdellah) of these programs later conceptualized nursing science (George, 2002). As the number of nurses with higher education increased, nurses began to participate in research (Tomey&Alligood, 2002).
Theory development progressed in the 1960s. In 1965, ANA’s position paper concluded that theory development was one of the significant goals of nursing. ANA also supported efforts to develop the body of nursing to ultimately create a nursing science (ANA, 1965; Meleis, 1997 as cited in Potter & Perry, 2001). But what is Nursing Science? It is “the body of knowledge generated through the application of research process to events of concern to the discipline of nursing” (Lindeman &McAthie, 1999, p. 25). Nursing science produced knowledge for nursing practice through research. Cody (1997) also provided his definition as such: …nursing science is the essence of nursing as a scholarly discipline; without it, there would be no nursing, only care…As a science, nursing’s richness is manifest in the availability of the cutting-edge philosophies and theories to provide guidance for practice…and a growing body of literature describing nursing theory-based practice…(pp. 12-13).
In the 1970s the “nursing profession viewed itself as a scientific discipline” (McEwen & Wills, 2007, p. 33). It had pluralistic definitions defined by many theorists as nursing moved toward the goal of developing nursing knowledge upon which to base practice. The definition by several nursing leaders articulated nursing as “knowledge-based, patient focused, and involving skills” (Brooks & Klein-Kracht, 1983, p. 57). This time was also referred as the nursing theory era which followed the research era. It became clear that research without theory produced isolated information. However, nursing science is produced by theory and research (Tomey&Alligood, 2002).Nursing science was highly influenced by logical positivism, a philosophical thought which “recognized only the logical and empirical base of science and there is no room for metaphysics, understanding, or meaning within the realm of science” (Polifroni& Welch, 1999 as cited in McEwen & Wills, 2007, p. 9). Nursing practice was determined by theory and research, and nursing at this time was considered an applied science (Lindeman &McAthie, 1999).
Many nursing theories emerged during this decade. The integration of theories and process (method of applying the theories), became the basis for professional nursing (Potter & Perry, 2001). Nursing, at this point, had acquired many of the characteristics of a profession: a growing knowledge base, authority over training and education, altruistic service, code of ethics, and registration requirements for practice; but to this date nursing’s autonomy in practice is incomplete because much of the practice is still directed by medicine (McEwen & Wills, 2007). Nonetheless, it can be said that “nursing is an aspiring, evolving profession” (Smith, 2000 as cited in McEwen & Wills, 2007, p. 4). As early as 1932, ANA (formerly the Nurses’ Associated Alumni in 1912) already issued the statement of the role of nurses and the nursing profession:
Professional nursing is a blend of intellectual attainment, attributes and mental skillsbased upon the principles of scientific medicine, acquired by means of a prescribed course in a school of nursing affiliated with a hospital …and practice in conjunction with curative and preventative medicine by an individual licensed to do so (Brooks & Klein-Kracht, 1983, p. 54).
What is nursing at present? Where is Nursing going? What is it in search of?
Nursing at present
Nursing at present can be understood as an emerging profession, and an academic discipline. It is also a human science (Mitchell & Cody, 1992). Nursing practice today is an “interaction of the processes of knowing and doing” (Lindeman &McAthie, 1999, p. 35). The nurse of today is a knowledge worker, one who is consciously using knowledge while implementing and evaluating every nursing action (Lindeman &McAthie, 1999).
Where is nursing going?
Nursing will continue to face the challenges in terms of knowledge development. As an emerging discipline (branch of educational instruction), it was influenced by logical positivism, and thus knowledge generation has stressed traditional, orthodox, and experimental methods, but this era has challenged this viewpoint because nurses are now torn between emphasizing a humanistic holistic focus or objectively and scientifically derive means of comprehending reality (McEwen & Wills, 2007). It is the contention of Brooks & Klein-Kracht(1983) that nursing has returned to its humanistic philosophical aspects and that it is going back to the basics to “recapture its roots.”
Similarly, most nursing scholars agree that positivism, empiricism, and logical positivism are “fundamentally incompatible with the (nursing) discipline’s complex philosophical commitment to holism and the humanistic approach, therefore it (positivism) it has been essentially discarded as a basis for the science in nursing” (Di Bartolo, 1998, p. 353 as cited in McEwen & Wills, 2007, p. 10). This view favors the perceived view and the use of qualitative methodology to generate scientific knowledge. On the other hand, McEwen & Wills (2007) posits that “what is needed is an open philosophy that ties empirical concepts that are capable of validating through the senses with the theoretical concepts of meaning and value” (p. 19).
Contemporary nursing continues to develop knowledge which is impacted by nursing theory and research. Nursing at this age and time is in need of pluralistic methodology to generate scientific knowledge as it has moved from an occupation to a profession. The fallibility of both approaches (quantitative and qualitative) methods may just ironically be complementary to each other.
In terms of theory development, newer models of practice have now emerged. These are the “Reflective Practitioner” model of Schon (1987) and the “Expert Practitioner” model of Benner (1984) which view knowledge as coming from many sources (such as practice or experience), not just from theory and research (Lindeman &McAthie, 1999). In this present age, it is not only empirics which is the source of nursing knowledge but nursing epistemology has to utilize the different patterns of knowing to guide practice such as Carper’s (1978) four patterns of knowing. These are: empirical (the science of nursing); esthetics (the art of nursing); personal knowing ( the therapeutic use of self); and ethical (moral component) (Berman et al, 2008)
What is it in search of?
Nursing to this day is still in search of nursing knowledge. This search is evident in the statement “ The knowledge that constitutes the discipline has not yet been identified and structured, and agreement has not been reached concerning appropriate and needed inclusions”.( Schlotfeldt, 1992 as cited by McEwen et al, 2007).
Nursing will continuously be defined in the process of its existence; but Storlie states that “the danger of definition is loss of mystery, loss of aura and diminishing beauty…” (as cited in Brooks & Klein Kracht, 1983, p. 61). Today, nursing is still impacted by a myriad of factors— from client demography, economy, education, nurse leaders and scientists, religion, and even by wars. It will continue to evolve as it always had.
In conclusion, within the scope of this paper, the historical landmarks in the journey of nursing include: rendering of dedicated and pious service during the early civilization; the start of modern nursing which is attributed to the humanitarian influence of Florence Nightingale in the 19th century; the realization that trained nurses are indispensable in quality patient care. In addition, theory development and nursing science emerged in the 20th century and nursing research also had a breakthrough. Consequently, nursing is now considered an emerging profession, an academic discipline and a human science. The future still challenges nursing to generate more knowledge to inform practice.
There may be twists and turns as it continues its journey. Quo vadis? Only time can tell…
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